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FAME Neurology Clinic – Days 1 and 2

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It’s an early day leaving the house as Payal has her first of three lectures to give to the nursing staff today. Brad, our new education coordinator told us yesterday that there was a significant chance that no one would show up for today’s lecture as the nurses would have to be picked up early from town to make a lecture that early and in all likelihood they will have forgotten over the weekend. He was right. Sahawa, our nurse anesthetist, was the only one to show for the lecture, but that was fine since it gave Payal a good chance to practice her lecture as she will be giving it on two other occasions so all the nurses have a chance to hear it.

After lecture it was off to our neurology clinic here at FAME. As they have outgrown the outpatient clinic even without our specialty clinic our plan was to see patients across the courtyard in the emergency room and night doctor’s office. That would allow us to have two rooms working at a time and we had one clinical officer to work with a resident and an interpreter with the other. I would hang out mostly with the interpreter/resident pair as that would require a bit more supervision.

Busy day at FAME

Karatu Ambulance Service

Busy day at FAME

I will begin by telling you that Monday turned out to be a record setting day at FAME due to the numbers of patients and our Monday neurology clinic ended up being the greatest number of neurology patients we’ve seen in a day here – thirty-four. It is really a testament to the work by our outreach coordinator, William Mhapa, who is a real powerhouse. Every patient we saw was an appropriate neurology patient which is so important so as not to waste our time trying to triage during the day with so limited an amount of time to do everything. Payal was seeing all the pediatrics and Christyn was seeing all of the adults.

Christyn examining a patient

Payal evaluating a young girl with hemiplegia and epilepsy who I have followed for four years

I will have to say that a great majority of the adult patients were headache patients, but otherwise we had a great diversity of diagnoses in both the adult and pediatric patients seen. We worked until rather late and I drove Sokoine, our interpreter, back to town since we had made him miss the vehicle heading down having worked so late. We also drove two bebes (older women) who were at the clinic late down to town. We had dinner on Joyce’s large veranda with everyone including two surgeons who are visiting for just the week deciding if they would like to commit to a longer term relationship. They would be a great asset to FAME as there are many surgical cases that come through but most of all wound care for all the burns they see here many of whom are children.

Christyn giving her stroke lecture

Tuesday mornings begin with the doctor’s education lecture at 7:30 and Christyn did an amazing job covering hemorrhagic and ischemic stroke using two case studies that were interactive. It was very well attended with all the doctors, visiting nurse practitioners, and clinical officers and there were lots of questions. We’ve given the lecture numerous times before, but since it’s something they don’t do on a regular basis it very hard to change how people practice. The same problem exists back home, though, and is not unique to East Africa. We are going to begin writing protocols for them to use here for management of neurologic problems like stroke and status epilepticus that should help greatly going forward.

Christyn evaluating a young Maasai women with epilepsy

Christyn and I saw a gentleman with a history of atrial fibrillation that came in with a complaint of headache. His headache had been present for several years, but a year ago he had had onset of focal neurologic symptoms including a complaint of some language difficulty and had gone to Arusha to have a CT scan at Aga Khan which they hadn’t brought with them. They told us that nothing was found on the CT scan which didn’t make sense so they went home (luckily they lived very close) and brought in the scan. Of course it wasn’t normal, but showed an acute left posterior MCA infarct as well as at least one other subcortical infarct. It was obvious that he needed to be on Coumadin to prevent any further events and that was taken care of.

Payal evaluating a young man with delay and previous surgery – no history available

At noon, Payal had gone to lunch at the Lilac Cafe (the little restaurant on campus) since lunch for the workers was Ugali and meat and Christyn had already gone up to the canteen. I was just walking up when one of the nurses brought a young boy over from the clinic who had just seized and was post-ictal. He was on a gurney and quite stable at the time so I put him in Payal’s room with his mom and went to grab a quick bite. Payal returned to find the boy in her exam room, but I got to her quickly to explain the situation and it turned out that he had been refusing his medications and it was unclear how much he had been getting. His mother was excellent and described how they were crushing the medication and putting it in his mouth while holding his nose so he would have to swallow, but it was still unclear if he was getting the full dose. We wheeled him into the hallway as Payal wanted him to stay until he was awake and functioning, but he later had another brief seizure that she was able to witness and she wanted him to come in at least overnight to observe him. Mom didn’t have the money needed to pay for the night in the hospital (20,000 TSh or less then $12) so we told her we would take care of the cost for the visit. I had been given some money by a generous friend to help with situations, but either way, we would have merely reached in our own pockets if necessary and that is how it happens here so often.

Patients are put on medications that cost a pittance in our minds, but are out of the question for them so they are stopped and their problem returns and that’s very often seizures. We now have a grant from LinkedIn to work on epilepsy here that will hopefully allow us to subsidize the cost of lifelong medications for these epilepsy patients and allow them to remain seizure free.We are also hoping to bring an EEG machine here in October to allow us to more accurately diagnose our patients rather than doing it by trial and error and seeing whether a medication works or makes them worse to know that it’s the right one. Danielle Becker will be working on that project and given the impact that uncontrolled epilepsy has on one’s life it should make a tremendous difference to overall health of the region here. Epilepsy is incredibly prevalent in Sub-Saharan Africa and the overall impact on disability and health is tremendous. Though this will be a huge undertaking it will clearly make a difference for the residents here on many levels. I am looking forward to watching that happen during my tenure here.

Since it was my birthday on Monday and though I had managed to keep it quiet, it somehow leaked out (thanks to Facebook with Kim and Susan) and we had a get together at the Lilac after work. A bunch of us had also made plans to go to Gibb’s Farm for dinner (having nothing to do with my birthday) so we headed up there after a quick visit at the Lilac. Gibb’s Farm is the true Shangi La and they offer a local’s rate of $25 for a four course dinner that would rival anything and is probably one of the finer dinners one can eat in Africa. The view from Gibb’s is also spectacular and we sit on the veranda there for at least an hour before dinner is served so it is a whole evening affair. Of course, Joyce wouldn’t allow me to pay for anything since it was my birthday the day before and it was such an enjoyable evening that I didn’t fight her on it (she reminded me to respect my elders!). We drove down the long road back from Gibb’s at 10PM and there were so many stars in the sky that is was absolutely crazy. The Milky Way rode over our heads in total brilliance. I was looking forward to a restful night in the cool air of the Ngorongoro Highlands with all the relaxing sounds of the wild here. I closed my eyes to the distant howl of a lonely hyena disturbing the local dogs and wondered what tomorrow would bring.